Edited by: Beate Schrank, Karl Landsteiner University of Health Sciences Tulln, Austria
Reviewed by: Leandro Da Costa Lane Valiengo, University of São Paulo, Brazil; William H. Fisher, Brandeis University, United States
This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry
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This paper presents data from a national census of patients in adult mental health outpatient clinics in Norway. It provides prevalence of outpatients who care for children under the age of 18 years, prevalence of parents whose children are considered by clinicians to require further support and are referred to external agencies, and how parents' socio economic and clinical characteristics influence prevalence and type of referrals made by clinicians for the children. This information can be used by policy makers and managers to strengthen policy, as well as to support clinicians to better identify parents, determine their children's needs and refer the children to appropriate services.
Parental mental illness impacts on the functioning of the family unit and poses a risk to the healthy development of children. Compared to other children, those growing up with a parent with a mental illness are at risk of a range of adverse behavioural, developmental and emotional outcomes (
Evidence suggests that children whose parents have a mental illness have almost double the chance of developing a mental illness themselves (
A recent systematic literature review found that between 12 and 45% of all patients attending adult mental services were parents (
To the best of our knowledge only one study has examined whole-of-service data for parental mental health prevalence. In the early 2000s, Maybery et al. (
When assessing the risks to such children, it is essential to obtain information about the parent, including diagnosis, gender, socio economic context, and family networks, as well as other circumstances which may influence children's experiences and outcomes. For example, parents who have an anxiety disorder are less likely to grant their children autonomy and more likely to demonstrate lower levels of sensitivity (
The family environment, including the presence of marital discord, the presence or absence of the other parent and the availability of social support to the family may also influence the level of risk exposure to the children (
Other studies have considered parent and family variables when determining prevalence. A 4-year census in one Australian adult mental health service identified that a majority of female outpatients were parents (
It is important that adult mental health services are responsive to the needs of children in these families, which at a minimum would involve identifying children, assessing their needs, and as required, referring them on to appropriate services (
Research has clearly demonstrated the benefits of family focused practice for parents with a mental illness, their children and other family members (
In Norway, specialized mental health services are organised in general hospital services across 19 health trusts. The division of mental health and addiction services in each health trust has inpatient and outpatient services for children and adolescents, adults, and older persons. Community mental health centres for adults include all outpatient mental health clinics, mobile teams, day units and almost half of the mental health inpatient beds in Norway (
The Norwegian Health Personnel Act of 2010 requires health personnel to ascertain whether a patient has minor children and if so, to record this in their patient record. The law also stipulates that clinicians should talk with the patient about their children's needs and offer to give information and guidance. Within the limits of confidentiality, clinicians might invite children to be involved in conversations about their parents' illness, treatment, and the possibility of visiting the service treating their parent. In addition, the law stipulates that clinicians assess the needs of the children and refer children to relevant services such as child protection agency, CAMHS, educational-psychological services in schools and family counselling offices as required (
The study aimed to determine the number and characteristics of adult outpatients who care for children under the age of 18, from a national outpatient census in mental health services in Norway. A further aim was to identify the prevalence of outpatients with minor children where the clinician identified a need for referral of children to an external agency.
The paper addresses the following research questions: 1. What is the prevalence of outpatients in adult mental health clinics who care for children under the age of 18 years? 2. What are the socio-demographic and clinical characteristics of these outpatients, compared to outpatients who do not care for minor children (in terms of diagnosis, gender, age, marital status, income, education level, housing, refugee status, and country of birth)? 3. For what prevalence of outpatients with minor children do clinicians identify a need for referral of children to an external agency for children, and what agencies are the children referred to? 4. What patient characteristics are associated with referral of children to external agencies?
The design of the census was a cross-sectional study of outpatients seen by all outpatient clinics and mobile teams in adult Norwegian mental health services during 2 weeks in April 2013. The census was commissioned and financed by the Norwegian Directorate of Health. The work was undertaken by the SINTEF research foundation. The study was approved by the Regional Committee for Medical and Health Research Ethics (reg.no. 2012/848).
The sample consisted of data on 23,167 adult outpatients seen by 107 of the 110 mental health outpatient clinics in Norway. The prevalence of outpatients included was 60% based on data from the National Patient Register indicating that the total number of outpatients during the 2 weeks was 38,904. The clinics that did not participate were small and cited a lack of time for not participating; these comprised 1% of all outpatient consultations during the 2 weeks.
The census form included outpatients' socio-demographic data (gender, age, and marital status, main source of income, highest education, housing situation, refugee status, and country of birth), main mental diagnoses using ICD-10 (for substance use disorders secondary diagnosis is also included, as this is often listed as a secondary diagnosis for patients with both a mental and a substance use disorder), and the following questions about patients' children: (1) Does the patient care for children under 18 years? (yes/no/unknown). (2) If yes, number of children. (3) Have measures been taken to follow up any of the children? (available response being; yes; no and no need to refer; no and a need to refer; unknown). (4) What agencies were children referred to (possible to mark more than one of the listed agencies).
All outpatients who had one or more consultations in 2 weeks (15–28 April 2013) were targeted. Several months prior to the census, service managers and clinicians received information about the census and the data collection procedures. Data were collected on hard copy forms. The clinicians completed one anonymous form for each outpatient. They were encouraged to invite the patients to participate in filling in the form, and 57% of the patients participated. The completed forms were returned to a data collection company, who scanned the forms and delivered data files to the project team.
Descriptive statistics, chi square testing and logit regressions were computed with STATA 15.
Of the 23,167 registered outpatients, information on gender and children was given for 22,398 (97%) of patients. A total of 8,035 (36%) of these had children under age 18, with 5,729 (71%) being female and 2,306 (29%) male.
Bivariate chi square analyses of associations between the patient characteristics in
Bivariate analyses of the association between patient characteristics and outpatients (
Female | 8,425 | 5,729 | 262 | 14,416 | 40 | |
Male | 5,938 | 2,306 | 187 | 8,431 | 28 | |
18–23 years | 3,258 | 249 | 69 | 3,576 | 7 | |
24–29 years | 2,919 | 1,029 | 74 | 4,022 | 26 | |
30–39 years | 2,603 | 2.965 | 81 | 5,649 | 53 | |
40–49 years | 1,935 | 2,666 | 93 | 4,694 | 58 | |
50–59 years | 1,805 | 765 | 52 | 2,622 | 30 | |
60–69 years | 850 | 95 | 20 | 965 | 10 | |
70 years and above | 672 | 59 | 31 | 762 | 8 | |
High education | 2,432 | 2,251 | 60 | 4,743 | 48 | |
Medium education | 6,289 | 3,597 | 131 | 10,017 | 36 | |
Low education | 5,772 | 2,267 | 325 | 8,364 | 28 | |
Income from labour | 3,164 | 2,922 | 77 | 6,163 | 48 | |
Health related benefit | 7,762 | 4,179 | 175 | 12,116 | 35 | |
Other economic support | 3,567 | 1,014 | 264 | 4,845 | 22 | |
Married/cohabitant/partner | 3,712 | 5,203 | 106 | 9,021 | 58 | |
Separated/divorced/widower/widow | 1,624 | 1,355 | 64 | 3,043 | 45 | |
Single/unmarried | 9,061 | 1,466 | 190 | 10,717 | 14 | |
Alone with or without children | 7,033 | 2,704 | 172 | 9,909 | 28 | |
Spouse/cohabitant | 3,596 | 5,090 | 98 | 8,784 | 59 | |
Other household | 3,705 | 201 | 79 | 3,985 | 5 | |
Own house | 5,156 | 5,306 | 125 | 10,587 | 51 | |
Rented house/apartment, private market | 4,298 | 1,868 | 95 | 6,261 | 30 | |
Rented house/apartment, local authorities | 1,466 | 341 | 27 | 1,834 | 19 | |
Other | 3,305 | 361 | 72 | 3,738 | 10 | |
Very good | 4,169 | 2,642 | 113 | 6,924 | 39 | |
Good | 6,325 | 3,561 | 124 | 10,010 | 36 | |
Poor | 1,998 | 979 | 43 | 3,020 | 33 | |
Very poor | 715 | 251 | 30 | 996 | 26 | |
Very good | 3,013 | 2,078 | 65 | 5,156 | 41 | |
Good | 6,531 | 3,881 | 152 | 10,564 | 37 | |
Poor | 2,180 | 996 | 58 | 3,234 | 31 | |
Very poor | 825 | 238 | 22 | 1,085 | 22 | |
< 3 | 1,567 | 847 | 72 | 2,486 | 35 | |
3–5 | 1,551 | 1,009 | 37 | 2,597 | 39 | |
6–9 | 1,601 | 1,007 | 40 | 2,648 | 39 | |
10–19 | 2,345 | 1,381 | 70 | 3,796 | 37 | |
20–39 | 2,321 | 1,355 | 47 | 3,723 | 37 | |
40–99 | 2,155 | 1,204 | 43 | 3,402 | 36 | |
100–199 | 1,064 | 484 | 28 | 1,576 | 31 | |
200 or more | 725 | 185 | 12 | 922 | 20 | |
No | 14,426 | 8,071 | 513 | 23,010 | 36 | |
Yes | 67 | 44 | 3 | 114 | 40 | |
No | 14,093 | 7,768 | 496 | 22,357 | 36 | |
Yes | 400 | 347 | 20 | 767 | 46 | |
No | 12,973 | 6,903 | 466 | 20,342 | 35 | |
Yes | 1,520 | 1,212 | 50 | 2,782 | 44 | |
No | 12,329 | 7,608 | 471 | 20,408 | 38 | |
Yes | 2,164 | 507 | 45 | 2,716 | 19 | |
No | 13,866 | 8,019 | 500 | 22,385 | 37 | |
Yes | 627 | 96 | 16 | 739 | 13 | |
No | 10,680 | 6,709 | 413 | 17,802 | 39 | |
Yes | 3,813 | 1,406 | 103 | 5,322 | 27 | |
Personality disorders | 1,118 | 640 | 33 | 1,791 | 36 | |
Substance use disorders (as first or second diagnosis) | 1,058 | 241 | 27 | 1,326 | 19 | |
Schizophrenia etc. | 1,902 | 295 | 52 | 2,249 | 13 | |
Affective disorders | 3,982 | 2,690 | 94 | 6,766 | 40 | |
Anxiety disorders | 3,128 | 2,455 | 90 | 5,673 | 44 | |
Behavioural syndromes | 552 | 221 | 14 | 787 | 29 | |
Behavioural and emotional disorders | 557 | 418 | 16 | 991 | 43 | |
Other mental illness | 1,320 | 619 | 27 | 1,966 | 32 |
Gender, diagnosis and prevalence of outpatients (
Female | 5,729 | 40 | 41 | 43 | 15 | 17 | 16 |
Male | 2,306 | 28 | 47 | 31 | 21 | 18 | 24 |
Personality disorders | 635 | 37 | 49 | 38 | 13 | 30 | 29 |
Substance use disorders (as first or second diagnosis) | 240 | 19 | 61 | 19 | 20 | 27 | 30 |
Schizophrenia etc. | 293 | 13 | 67 | 14 | 18 | 19 | 29 |
Affective disorders | 2,669 | 40 | 42 | 44 | 14 | 16 | 16 |
Anxiety disorders | 2,429 | 44 | 36 | 49 | 15 | 15 | 15 |
Behavioural syndromes | 219 | 29 | 33 | 37 | 30 | 12 | 13 |
Behavioural and emotional disorders | 412 | 43 | 43 | 36 | 21 | 15 | 13 |
Other mental illness | 613 | 32 | 36 | 37 | 27 | 15 | 18 |
In a logistic regression analysis of associations between the odds ratio for caring for children under 18 and the same patient characteristics (
Logistic regression of the association between patient characteristics and whether the outpatients (
Male | 0.676 | 0.028 | −9.37 | 0.00 | 0.623 | 0.734 |
18–23 years | 1.000 | (base) | ||||
24–29 years | 3.029 | 0.274 | 12.25 | 0.00 | 2.537 | 3.617 |
30–39 years | 8.114 | 0.724 | 23.46 | 0.00 | 6.812 | 9.665 |
40–49 years | 7.821 | 0.730 | 22.02 | 0.00 | 6.512 | 9.392 |
50–59 years | 1.666 | 0.168 | 5.07 | 0.00 | 1.367 | 2.029 |
60–69 years | 0.349 | 0.051 | −7.21 | 0.00 | 0.262 | 0.464 |
70 years and above | 0.213 | 0.037 | −8.80 | 0.00 | 0.151 | 0.300 |
High education | 1.000 | (base) | ||||
Medium education | 1.033 | 0.050 | 0.67 | 0.51 | 0.939 | 1.136 |
Low education | 1.167 | 0.065 | 2.75 | 0.01 | 1.046 | 1.303 |
Income from labour | 1.000 | (base) | ||||
Health related benefits | 0.857 | 0.039 | −3.36 | 0.00 | 0.784 | 0.938 |
Other economic support | 1.062 | 0.071 | 0.89 | 0.37 | 0.930 | 1.211 |
Married/cohabitant/partner | 1.000 | (base) | ||||
Separated/divorced/widow/widower | 0.842 | 0.117 | −1.23 | 0.22 | 0.641 | 1.106 |
Single/unmarried | 0.168 | 0.023 | −12.99 | 0.00 | 0.128 | 0.220 |
Alone with or without children | 1.000 | (base) | ||||
Spouse/cohabitant | 0.832 | 0.113 | −1.35 | 0.18 | 0.637 | 1.086 |
Other type of household | 0.298 | 0.031 | −11.67 | 0.00 | 0.243 | 0.365 |
Own house | 1.000 | (base) | ||||
Rented house/apartment, private marked | 0.647 | 0.031 | −9.10 | 0.00 | 0.589 | 0.710 |
Rented house/apartment, local authorities | 0.564 | 0.049 | −6.60 | 0.00 | 0.476 | 0.669 |
Other accommodation | 0.638 | 0.058 | −4.92 | 0.00 | 0.534 | 0.763 |
0.906 | 0.048 | −1.88 | 0.06 | 0.817 | 1.004 | |
0.820 | 0.043 | −3.79 | 0.00 | 0.740 | 0.909 | |
0.870 | 0.035 | −3.49 | 0.00 | 0.805 | 0.941 | |
1.399 | 0.163 | 2.87 | 0.00 | 1.112 | 1.759 | |
1.156 | 0.074 | 2.27 | 0.02 | 1.020 | 1.311 | |
0.731 | 0.051 | −4.53 | 0.00 | 0.638 | 0.837 | |
0.838 | 0.120 | −1.24 | 0.22 | 0.633 | 1.109 | |
0.681 | 0.032 | −8.20 | 0.00 | 0.622 | 0.747 | |
Personality disorders | 1.000 | (base) | ||||
Substance use disorders (as first or second diagnosis) | 0.627 | 0.068 | −4.31 | 0.00 | 0.507 | 0.775 |
Schizophrenia spectrum disorders | 0.406 | 0.041 | −8.90 | 0.00 | 0.333 | 0.495 |
Affective disorders | 1.047 | 0.074 | 0.65 | 0.52 | 0.911 | 1.204 |
Anxiety disorders | 1.038 | 0.075 | 0.52 | 0.60 | 0.901 | 1.197 |
Behavioural syndromes | 0.718 | 0.088 | −2.71 | 0.01 | 0.565 | 0.912 |
Behavioural and emotional disorders | 1.528 | 0.164 | 3.95 | 0.00 | 1.238 | 1.886 |
Other mental illness | 1.083 | 0.101 | 0.85 | 0.39 | 0.902 | 1.301 |
Constant | 0.712 | 0.129 | −1.88 | 0.06 | 0.500 | 1.015 |
The data on the number of children identified by clinicians to require referral to an external agency is shown in
Reported needs and whether measures have been taken to follow up of the children of outpatients (
Yes child/ren have needs | 2,488 | 31 |
No, but have needs | 247 | 3 |
No, but does not have any needs | 4,670 | 58 |
Do not know | 257 | 3 |
No answer | 373 | 5 |
Number of outpatients with responsibility for children under age 18 | 8,035 | 100 |
The clinicians answered the question on whether measures have been taken for referral for the children for 7,405 (92%) outpatients. Of these, 2,488 (31%) were reported to require referral to an agency. Of the 4,917 (61%) outpatients with children reported as not being referred, 247 (3%) were still reported to need a referral. This indicates that for 34% of the parents a referral of their children was identified as required, that some of these were not referred, and that children of 58% of the parents were reported to not require a referral. The need for referral is unknown for children of 630 (8%) of outpatients with minor children, including those who responded with “Do not know” and those with missing answers. Patients were involved in filling in the form in 61% of cases where the patient was a parent (
Information on the referral agencies is presented in
Prevalence of outpatients (
Child protection agency | 1,128 | 45 |
Family counselling office | 165 | 7 |
Educational-psychological service/ school | 861 | 35 |
Child and adolescent mental health service | 975 | 39 |
Adult mental health outpatient clinic | 83 | 3 |
Other | 544 | 22 |
No answer | 46 | 2 |
Bivariate chi square analyses of associations between the patient characteristics and whether measures were taken to refer children are shown in
Bivariate analyses of characteristics of outpatients with children (
Female | 3,479 | 1,977 | 273 | 5,729 | 35 | |
Male | 1,695 | 511 | 100 | 2,306 | 22 | |
18–23 years | 169 | 67 | 11 | 247 | 27 | |
24–29 years | 673 | 305 | 43 | 1,021 | 30 | |
30–39 years | 1,839 | 959 | 135 | 2,933 | 33 | |
40–49 years | 1,661 | 847 | 138 | 2,646 | 32 | |
50–59 years | 530 | 213 | 21 | 764 | 28 | |
60–69 years | 79 | 11 | 4 | 94 | 12 | |
70 years and above | 55 | 3 | 1 | 59 | 5 | |
High education | 1,631 | 508 | 89 | 2,228 | 23 | |
Medium education | 2,303 | 1,111 | 150 | 3,564 | 31 | |
Low education | 1,240 | 869 | 134 | 2,243 | 39 | |
Income from labour | 2,107 | 658 | 126 | 2,891 | 23 | |
Health related benefit | 2,460 | 1,494 | 187 | 4,141 | 36 | |
Other economic support | 607 | 336 | 60 | 1,003 | 33 | |
Married/cohabitant/partners | 3,587 | 1,319 | 250 | 5,156 | 26 | |
Separated/divorced/widower/widow | 723 | 564 | 51 | 1,338 | 42 | |
Single/unmarried | 807 | 580 | 66 | 1,453 | 40 | |
Alone with or without children | 1,472 | 1,094 | 110 | 2,676 | 41 | |
Spouse/cohabitant | 3,498 | 1,304 | 243 | 5,045 | 26 | |
Other household | 133 | 56 | 8 | 197 | 28 | |
Own house | 3,621 | 1,386 | 247 | 5,254 | 26 | |
Rented house/apartment, private marked | 1,044 | 732 | 73 | 1,849 | 40 | |
Rented house/apartment, local authorities | 149 | 182 | 7 | 338 | 54 | |
Other | 216 | 124 | 17 | 357 | 35 | |
Very good | 1,817 | 685 | 115 | 2,617 | 26 | |
Good | 2,266 | 1,097 | 164 | 3,527 | 31 | |
Poor | 527 | 404 | 36 | 967 | 42 | |
Very poor | 129 | 114 | 5 | 248 | 46 | |
Very good | 1,430 | 543 | 82 | 2,055 | 26 | |
Good | 2,430 | 1,244 | 173 | 3,847 | 32 | |
Poor | 581 | 359 | 40 | 9,80 | 37 | |
Very poor | 144 | 83 | 10 | 237 | 35 | |
Less than 3 | 578 | 215 | 48 | 841 | 26 | |
3–5 | 684 | 259 | 51 | 994 | 26 | |
6–9 | 670 | 274 | 56 | 1,000 | 27 | |
10–19 | 912 | 374 | 78 | 1,364 | 27 | |
20–39 | 856 | 435 | 50 | 1,341 | 32 | |
40–99 | 720 | 437 | 37 | 1,194 | 37 | |
100–199 | 271 | 199 | 11 | 481 | 41 | |
200 or more | 80 | 100 | 4 | 184 | 54 | |
No | 5,148 | 2,472 | 372 | 7,992 | 31 | |
Yes | 26 | 16 | 1 | 43 | 37 | |
No | 4,942 | 2,395 | 357 | 7,694 | 31 | |
Yes | 232 | 93 | 16 | 341 | 27 | |
No | 4,427 | 2,093 | 316 | 6,836 | 31 | |
Yes | 747 | 395 | 57 | 1199 | 33 | |
No | 4,971 | 2,198 | 362 | 7,531 | 29 | |
Yes | 203 | 290 | 11 | 504 | 58 | |
No | 5,128 | 2,441 | 370 | 7,939 | 31 | |
Yes | 46 | 47 | 3 | 96 | 49 | |
No | 4,280 | 2,042 | 322 | 6,644 | 31 | |
Yes | 894 | 446 | 51 | 1,391 | 32 | |
Personality disorders | 353 | 261 | 21 | 635 | 41 | |
Substance use disorders (as first or second diagnosis) | 110 | 119 | 11 | 240 | 50 | |
Schizophrenia etc. | 166 | 115 | 12 | 293 | 39 | |
Affective disorders | 1,769 | 785 | 115 | 2,669 | 29 | |
Anxiety disorders | 1,648 | 661 | 120 | 2,429 | 27 | |
Behavioural syndromes | 152 | 55 | 12 | 219 | 25 | |
Behavioural and emotional disorders | 235 | 161 | 16 | 412 | 39 | |
Other mental illness | 385 | 191 | 37 | 613 | 31 |
Results of a logistic regression of the association between patient characteristics and odds ratios for referral of children is shown in
Logit regression of the association between patient characteristics and whether minor children of outpatients (
0.466 | 0.032 | −11.060 | 0.00 | 0.407 | 0.533 | |
18–23 years | 1.000 | (base) | ||||
24–29 years | 1.316 | 0.237 | 1.53 | 0.13 | 0.925 | 1.873 |
30–39 years | 1.986 | 0.343 | 3.97 | 0.00 | 1.416 | 2.785 |
40–49 years | 1.952 | 0.345 | 3.78 | 0.00 | 1.380 | 2.761 |
50–59 years | 1.702 | 0.332 | 2.73 | 0.01 | 1.161 | 2.495 |
60–69 years | 0.449 | 0.175 | −2.05 | 0.04 | 0.209 | 0.966 |
70 years and above | 0.123 | 0.092 | −2.79 | 0.01 | 0.028 | 0.535 |
1.000 | (base) | |||||
Medium education | 1.419 | 0.102 | 4.87 | 0.00 | 1.233 | 1.634 |
Low education | 1.896 | 0.156 | 7.77 | 0.00 | 1.613 | 2.228 |
1.000 | (base) | |||||
Health related benefits | 1.376 | 0.091 | 4.83 | 0.00 | 1.209 | 1.566 |
Other economic support | 1.361 | 0.136 | 3.07 | 0.00 | 1.118 | 1.657 |
1.000 | (base) | |||||
Separated/divorced/widow/widower | 2.534 | 0.512 | 4.60 | 0.00 | 1.705 | 3.766 |
Single/unmarried | 2.056 | 0.423 | 3.51 | 0.00 | 1.374 | 3.076 |
1.000 | (base) | |||||
Spouse/cohabitant | 1.427 | 0.284 | 1.79 | 0.07 | 0.966 | 2.107 |
Other type of household | 0.562 | 0.125 | −2.58 | 0.01 | 0.362 | 0.870 |
1.000 | (base) | |||||
Rented house/apartment, private marked | 1.337 | 0.097 | 4.02 | 0.00 | 1.161 | 1.541 |
Rented house/apartment, local authorities | 1.701 | 0.236 | 3.83 | 0.00 | 1.296 | 2.232 |
Other | 1.439 | 0.233 | 2.25 | 0.03 | 1.047 | 1.978 |
1.447 | 0.112 | 4.79 | 0.00 | 1.244 | 1.683 | |
1.032 | 0.083 | 0.40 | 0.69 | 0.882 | 1.209 | |
1.281 | 0.075 | 4.23 | 0.00 | 1.142 | 1.436 | |
2.232 | 0.247 | 7.27 | 0.00 | 1.797 | 2.771 | |
1.121 | 0.297 | 0.43 | 0.67 | 0.667 | 1.884 | |
Personality disorders | 1.000 | (base) | ||||
Substance use disorders (as first or second diagnosis) | 1.306 | 0.239 | 1.46 | 0.14 | 0.913 | 1.870 |
Schizophrenia spectrum disorder | 0.857 | 0.147 | −0.90 | 0.37 | 0.612 | 1.198 |
Affective disorders | 0.774 | 0.080 | −2.48 | 0.01 | 0.633 | 0.947 |
Anxiety disorders | 0.684 | 0.072 | −3.64 | 0.00 | 0.557 | 0.839 |
Behavioural syndromes | 0.606 | 0.116 | −2.61 | 0.01 | 0.416 | 0.883 |
Behavioural and emotional disorders | 1.174 | 0.172 | 1.09 | 0.27 | 0.880 | 1.565 |
Other mental illness | 1.124 | 0.155 | 0.85 | 0.40 | 0.858 | 1.472 |
Constant | 0.099 | 0.028 | −8.05 | 0.00 | 0.056 | 0.174 |
In the current study one third of adult outpatients from 107 Norwegian mental health outpatient clinics cared for children under 18 years of age. One third of those parents had children who required a referral, six out of 10 had children not requiring a referral, and for one in 10 parents, the needs of their children was unknown or not reported. Children of three of 10 outpatient parents were reported to have been referred to relevant services. Patient characteristics associated with referral actions for their children were low education, being single, not owning a house/apartment, having a poor family network, having an individual care plan, being female, and having moderate or a less severe mental illness.
Thirty-six percent of the outpatients in this study cared for children under 18 years of age. This falls within the range of 36–38% found in four previous studies identified in a systematic review of adult mental health services (
The results also provide greater certainty about the sociodemographic characteristics of parents and children in mental health services. Sociodemographic patient characteristics associated with higher odds ratios for caring for children under 18 were being age groups 30–49 and refugee, and characteristics associated with lower odds ratios were being male, single, not having own house/apartment, poor network of friends and not living in a large municipality. Forty percent of females and 28% of males cared for minor children. In terms of gender, others have shown somewhat similar results, with between 34 and 59% of all female patients recorded as mothers and 25–39% of all males as fathers (
Clinical patient characteristics associated with lower odds ratio for caring for children under 18 were longer outpatient care, having an individual care plan, and having a severe mental illness or a substance use disorder. These data would indicate that those with a severe illness by and large are not presenting to adult mental health services with children or are not disclosing that they have children. It might also be that those with severe mental illness are more often hospitalized and/or cared for by the community care teams than by mental health outpatient clinics, and that more parents with severe mental illness might have lost custody of their children and have little contact with the children. The fear of the involvement of child protection agency might dissuade patients who have a severe illness from disclosing their parenting status (
Forty-four percent of parents were reported to have an anxiety disorder, 40% an affective disorder, 43% a behavioural and emotional disorder, and 37% a personality disorder. In Australia, Fernbacher et al. (
For 92% of the outpatients with minor children the clinicians had identified if children required a referral to an external agency, and the need for referral was not ascertained for 8% of outpatients with minor children. Children of 61% of outpatient parents were not considered by clinicians to require a referral, even though 3% of these were still provided with a referral to an external agency. In Norway health personnel are required to ascertain whether a patient has minor children, talk with the patient about their children's needs and offer to give information and guidance. But there are no standard procedures or rules for referral of the patients' children. There may be capacity problem in the child and welfare services, as well as variations in resources and availability of such services. However, as shown in
Clinicians' actions did not necessarily align with their stated beliefs, an incongruence that has also been highlighted elsewhere (
Given the range of risk and protective factors for these children, not all children whose parent has a mental illness will be adversely affected (
Sociodemographic patient characteristics associated with higher odds ratio for children being referred were being female, single, low education, not owning a house/apartment, not receiving income from paid work, and a poor family network. Maybery et al. (
Having an individual care plan was associated with higher odds ratio for children being referred, while moderate to less severe mental illness was associated with lower odds ratio for children being referred. Though the odds ratio of children being referred were parents having a moderate to less severe psychiatric illness, the established individual care plan suggests that these are families with multiple problems, with a need for coordinated support. The poorer family network might also be an important explanation for the higher need for other types of support.
For 52% of the patients with minor children, children had been referred to child protection agencies (45%) and family counselling offices (7%). This is not surprising as the sociodemographic characteristics of the patients with children being referred might indicate a need for economic and practical help and social support as well as help to cope with the parental illness. Many children (39%) had been referred to the child- and adolescent services, indicating that the children needed treatment for their own mental and/or behavioral problems.
For one third (35%) of the families, children had been referred to educational-psychological services/school, which confirms the need for support found in a Swedish study. Hjern et al. (
Some explanatory variables in the logistic regression in
In this study, if the patient did not participate in filling in the form, the question on whether children are referred was more often (6%) answered with unknown compared to if the patient participated in filling in the form (2%). This supports the importance of clinicians involving the patient in assessing the needs of their children.
A major strength of the study is the large census-level sample from almost all the psychiatric outpatient clinics in one country. As the data was registered on anonymous forms and did not require written consent from the patients, there is no obvious reason to expect that the material is skewed due to subgroups being less reluctant to participate. Some clinicians did however indicate that completing the form was time-consuming and that they did not have time to include all their patients. A limitation is that the clinicians might have only included the less complicated cases to save time. It is also possible that outpatients who missed their appointed consultations were less likely to be included. An important limitation of the study compared with epidemiological studies is that only those who receive treatment were included. The prevalence numbers presented are valid for outpatients in specialist mental health treatment and not for the population suffering from mental illness in general. Finally, the results may not be representative of patients in other types of mental health services and in other countries.
The amount of missing data is a limitation, as is the small amount of information collected regarding patients' children. Information was only collected on whether children were considered to have needs and whether these needs warranted a referral to external agencies. It was not possibility to examine the quality and thoroughness of these assessments. Information was not collected on what children's needs were, nor whether referral actions were appropriate, implemented and ultimately successful at addressing children's needs. Future research could explore these factors.
The prevalence of outpatients in adult psychiatric clinics who care for children under the age of 18 years is 36% in this study of a sample from a national census in Norwegian adult mental health clinics. This provides considerable certainty regarding parent prevalence as the statistics emanate from a whole of country data set. The findings also add important information about the characteristics of higher risk families. Significant odds ratios among psychiatric outpatients being parents with care for minor children were highest for age groups 30–49 and refugees; and lowest for being single, male, not having own house/apartment, and having a schizophrenia spectrum disorder. Of the 92% of the patients with minor children where clinicians had answered whether measures have been taken for referral for the children, 31% were reported to have children having been referred, 58% did not have children requiring a referral, and 3% had children who had not been referred in spite of being identified as requiring a referral. The need for referral was unknown for children of 8% of the outpatients with minor children. The agencies most referred to were child protection agencies (45%), CAMHS (39%) and educational-psychological services in the school system (35%). The significant odds ratios for having children who required referral to an agency were highest for parents aged 30–59 who were single with low education, not having income from paid work, not owning a house/apartment, poor family network, having had many outpatient consultations, and having an individual care plan. The significant odds ratios were lowest for males and for having moderate or less severe psychiatric illness.
There are several practice and systems implications for the present results. Given the sizable minority of patients who are parents, adult mental health services require appropriate infrastructure systems and procedures to identify parenting status of patients, including those who may be pregnant. Treatment plans should address needs of parents and their children and include referral of parents and their children to early intervention services as appropriate. Referrals to child protection agencies should be carefully considered, once accurate and sensitive assessments of the family's strengths as well as vulnerabilities are made, including the family's personal and professional networks. Appropriate training could be offered to clinicians in adult mental health outpatient services, with particular attention on how mental illness impacts parenting and the range of services that families may be referred to.
Future studies need to investigate more broadly the family circumstances for children whose parents have mental illness, the specific actions of clinicians and the outcome of referrals for children. Why clinicians provide referrals for the children of some of their patients, but not others, could be further investigated. The pathways of care, as parents and children navigate various mental health and other systems (including but not limited to adult mental health, child protection services, schools), could be documented to determine what happens for families, areas of duplication/gaps, and outcomes for different family members, over time.
TR, DM, and SO contributed conception and design of the study with input from AR, KF, BW, BS, and AG. SO collected the data, organized the database and performed the statistical analyses. DM and TR wrote the first draft of the manuscript. AR, KF, BW, BS, AG, and SO wrote sections of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.